The business of sports medicine; 5 tips for survival! Jack M. Bert, MD

1. Get bigger if in private practice. Umbrella merge groups to

see if the relationship works. Advantages include improved payer negotiating ability, improved market share, ability to invest in ancillary services, increased capital to invest in technology to collect outcome data & ability to offer subspecialty services as examples.

2. Align with a hospital system. Reduces competitive threat if hospitals are considering hiring orthopedists. JV/co-management agreements and gain sharing arrangements will allow the group both marketplace security as well as a financial incentive to manage the hospital’s orthopedic service line.

3. Collect outcomes. Alternative payment models such as “bundled payments” are being offered to payers and employers by groups with outcome data confirming high quality at a low cost. Without data collection, payers and employers are reluctant to engage with providers.

4. Technology is critical. Determining the cost of bundles, managing the bundle, and optimizing the patient’s episode of care require relatively sophisticated in house technology. Determining outcomes and managing the surgical episode of care with appropriate software will allow the group to offer evidenced based high quality care which is attractive to both payers and employers.

5. Employed orthopedic surgeons. Must be aware and take advantage of their tremendous value to any hospital system. The commonly quoted “net value” of the employed surgeon’s income is approximately 5 to 1; i.e. net revenue generated compared to the mean salary of what the surgeon’s salary currently is.

Collecting Patient Data: Is it Really

Important

Conflict of Interest Statement• Consultant/Royalities – Arthrex• Fellowship Grants

• Arthrex – Thank you• Synthes – Thank you• Mitek – Thank you

• Share Holder • Tuckahoe Surgery Center & St. Mary’s ASC• Comp Recovery

• AANA Past President and Member of the Board of Directors• AAOS Coding, Coverage and Reimbursement Committee - member

AANA Clinical Outcome Initiative

Value = Outcomes/Cost

The New Reality

Cannot Determine Value Without Outcomes!

“There is a war out there in Medicine.The ammunition is data.

The doctors have none.” Lanny Johnson

“Whoever has the data, wins the war!”We simply need to mine the data!

Rotator Cuff AAOS CPGFull Thickness Tears in Symptomatic Patients

AAOS RecommendationRotator Cuff Repair is an Option for Patients with

Chronic, Symptomatic Full Thickness Tears

Strength of Recommendation:

WEAK

Reasons for Change End of Fee for Service – 2020? CMS 2018 - 50% of payments from alternatives Change from “Volume to Value”

VALUE = OUTCOMES/COST (WE MUST GET OUTCOMES!!) CMS Programs

MIPS APM

Negative Coverage Decision (NCD)!!

CMS/Insurer Data Collection Goal Performance Measures =

what differentiates good clinicians Requires huge data

Patient Reported Outcomes (PRO’s) - easier

AANA Clinical Outcome Initiative Goals of the Project

Collect Patient Reported Outcomes and Develop Performance Measures

Satisfy our data collection requirement – inexpensive/simple○ Insurers○ CMS – MIPS - MACRA

Avoid negative coverage decisions - meniscectomy Allow surgeons to privately evaluate/compare their individual

outcomes ->education patients, educate payors

Partnering for Better Patient Outcomes

700 723 732 746 775 787 800 823 830 838 849 861 889 905

326 348 350 352 361 366 370 372 374 368 373 387 389 392

12 12 12 12 12 12 12 12 13 13 15 17 18 220

100

200

300

400

500

600

700

800

900

1000

SOS Physician Enrollment

All SOS Enrollees

AANA Enrollees

EOA Enrollees

0 5000 10000 15000 20000 25000 30000

Hand & Wrist Non-Op

Elbow Non-Op

Foot & Ankle Non-Op

Cervical Spine

Hip Non-Op

Shoulder Non-Op

Subcervical Spine

Hand & Wrist

Elbow

Knee Non-Op

Foot & Ankle

Hip Arthroscopy

Shoulder Arthroplasty

Hip Arthroplasty

Knee Arthroplasty

Knee Arthroscopy

Shoulder Arthroscopy

37135179207351622626

10781294

19622587

49866029

1012212900

2318725580

93,000 Patients Enrolled in SOS

Knee Arthroscopy

Pediatric Knee

Knee Arthroplasty

Shoulder Arthroscopy

Shoulder Arthroplasty Elbow Hip

ArthroscopyHip

Arthroplasty F&A H&W

Spine (Cervical & Subcervical)

(Based on ICHOM)

VAS VAS VAS VAS VAS VAS VAS VAS VAS VAS NPRSVR12/

PROMIS10 PROMIS10 VR12/PROMIS10

VR12/PROMIS10

VR12/PROMIS10

VR12/PROMIS10

VR12/PROMIS10

VR12/PROMIS10

VR12/PROMIS10

VR12/PROMIS10

VR12/PROMIS10

KOOS/IKDC IKDC KOOS JR/

KOOS ASES-S ASES-S ASES-E M-HHS HOOS JR/HOOS

FAAM ADL/FFI-R QDASH Work Status

Marx Activity Scale

Marx/HSS Pedi FABS KSS Exp, Sat SANE SANE SANE SANE

Pt. reported Pain in Non-op

LE JointFAAM sport bMHQ Cont. Pain Med

SANE SANEPt. reported

Pain in non-op LE Joint

Penn Shoulder (PSS)

Penn Shoulder (PSS) KJOC HOS Pt. reported

back pain AOFAS CTS-6 Duration sick leave

IKDC IKDC Pt. reported back pain WOOS WOOS QDASH iHOT-12 Pt. reported

health literacy MOCART ROM, grip Comorbidities

Lysholm Pt. reported health literacy Oxford Oxford ASES-E Vail Hip HOOS Pinch,

strength, etc Duration pain

Tegner KOOS SST SST MEPI NAHS Oxford Deep wound infection

IKDC Oxford WOSI ASES-Obj MHHS Pulmonary embolus

MOCART KSS WORC Constant Harris Hip Need for rehospitalization

KJOC Need for reoperation

QDASH ODI (Sub)ASES-Obj NDI (cervical)

ISIS, Constant

Publications Challenging 29881 Sihvonen, R., Paavola, M., Malmivaara, A. et al. Arthroscopic partial meniscectomy versus sham

surgery for a degenerative meniscal tear. N Engl J Med. 2013; 369: 2515–2524 Moseley, J.B., O'Malley, K., Petersen, N.J. et al. A controlled trial of arthroscopic surgery for

osteoarthritis of the knee. N Engl J Med. 2002; 347: 81–88 Kirkley, A., Birmingham, T.B., Litchfield, R.B. et al. A randomized trial of arthroscopic surgery for

osteoarthritis of the knee. N Engl J Med. 2008; 359: 1097–1107 Herrlin, S., Hållander, M., Wange, P., Weidenhielm, L., and Werner, S. Arthroscopic or conservative

treatment of degenerative medial meniscus tears: A randomized prospective trial. Knee Surg Sports Traumatol Arthrosc. 2007; 15: 393–401

Katz, J.N., Brophy, R.H., Chaisson, C.E. et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013; 368: 1675–1684

Gauffin H, Tagesson S, Meunier A, Magnusson H, Kvist J. Knee arthroscopic surgery is beneficial to middle-aged patients with meniscal symptoms: a prospective, randomised, single-blinded study. Osteoarthritis Cartilage. 2014 Nov;22(11):1808-16.

Gauffin H, Sonesson S, Meunier A, Magnusson H, Kvist J. Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 3-Year Follow-up of a Prospective, Randomized Study. Am J Sports Med. 2017 Jul;45(9):2077-2084

NY State Medicaid Redesign Team Basic Benefit Review Work Group Final Recommendations – November 1,

2011 Recommendation: (C-2) Recommendation Short Name: Knee Arthroscopy Recommendation Long Name: Eliminate coverage of arthroscopy of the knee for osteoarthritis Premise: Medicaid should not cover the costs of knee arthroscopy for osteoarthritis because there is no

evidence of benefit. Program Area: OHIP Implementation Complexity: Implementation Timeline: Required Approvals: Low April 1, 2012 Administrative Action Plan Amendment Statutory Change Waiver Proposal Description: This proposal would limit coverage for arthroscopic

knee surgery when primary diagnosis is osteoarthritis of the knee (without mechanical destruction of the knee). The American Academy of Orthopedic Surgeons (AAOS) Board of Directors adopted The Clinical

Practice Guideline for the Treatment of Osteoarthritis of the Knee (Non-Arthroplasty) in December 2008. This evidence-based guideline recommends against performing arthroscopy with a primary diagnosis of OA of the knee.2 There is evidence that arthroscopic surgery for removal of loose debris, cartilage flaps, torn meniscal fragments, and inflammatory enzymes results in minimal pain relief and no functional benefit in patients that have joint space narrowing on standing radiographs.3

AANA’s - Outcomes Data Collection Provide our members with a turn-key system Minimal burden for the surgeons Inexpensive & without expensive maintenance System that avoids excessive regulations Unite similar societies – AANA, ASES & AAOS Determine our own metrics with consistent data

elements (AANA Favorites) GOAL – Share our data to protect patient access to care

(NCD)

Minimum Data Set and Research Sets Shoulder - Hawkins/Tokish

Core○ VR-12, SANE, ASES, ○ Oxford Shoulder Score

(for Europeans) Research

○ WORC (rotator cuffs)○ WOSI (shoulder instability)○ WOOS (shoulder

osteoarthritis)○ Penn Shoulder Score

(general)

SOS Value Highlights▪ Patient Reported Outcomes - Subjective▪ Automatic emails▪ Patient compliance tracking features▪ Co-morbidity indices for risk adjustment ▪ VR-12 for cost-effectiveness and QALY▪ “Favorite” templates▪ Smart Device and tablet compatible

▪ Surgeon “Administrative Burden” = 2 minutes post-op!!!!

AANA -> Key Partnerships Surgical Outcomes

System = specialized registry and clinical data registry

Provided Platform for data

collection Expertise and energy AANA grant for members

Hawkins Foundation = Qualified Clinical Data Registry

Seven CMS Applications for Clinical Performance Measures = expertise and energy

Can Report Quality Measures to CMS

The “Trifecta”

AANA /members = “the collectors/researchers”

SOS = the data collection platformHawkins Foundation = study

creation, data/analysis and reporting

Hawkins Foundation Performance Measures – ACCEPTED!!1. Surgical Recon for

ACL2. Knee Meniscectomy3. Knee Meniscal Repair4. Surgical Rotator Cuff

Repair

5. Shoulder Arthroscopy – 29823/26/286. Shoulder Arthroplasty-hemi/total/reverse7. Shoulder Instability/ Labral Repair

CERortho Risk Adjusted Patient Variables

Age Gender BMI Smoking Status Sports Participation WC status

Study Specific Data – Labrum Type of instability Labral tear location/size Concominant injuries Baseline shoulder measure

○ Pain○ Function○ Quality of life

Satisfy the Data Collection Mandate Hierarchy of the LAW Quality Payment Program (QPP)

Medicare Access and CHIP Reauthorization Act (MACRA)○ Merit Based Incentive Payment Program (MIPS) ○ Alternative Payment Modules

4 MIPS Categorieswww.qpp.cms.gov/mips/what-to-report

201860% of Total Score 25% of Total Score 15% of Total Score

The ASK! Engage Our Most Important Resource Will you (patient) help

me: Protect your “Access to

Care” “Thwart” the trend of

CMS/insurers to minimize the physician/patient’s autonomy for patient care

How a Busy Surgeon Can Do SOS! Minimize Surgeon

administrative burden Minimize assistant

time Maximize patient data

input Invest in your

business = hire/use an assistant!

Administrative assistant - KEY Surgery book and/or EHR schedule Contact patients by phone -> or real time kiosk/tablet Re-explain need/rationale for data collection Explain process – email surveys Obtain good email address Mail out a Surgical Outcomes System letter explaining the reasons

for your study and Research Participant HIPPA Authorization form. They must sign and return (research module, not HCO)

Use EHR to obtain demographics and MRI’s to enter data into the SOS system

Once completed go to the SOS site and enter the patient and surgical data

Patient Specifics Patient email - key Need to to

periodically answer email questionnaires

2 year commitment Surgeon – always

say “Thank-you!”

Surgeons Roll Perform the surgery Edits! the diagnosis

and surgical treatment Short learning curve

on the data input Follow-up with

patients, did you complete the email!

The Analysis

AANA’s Strategic Alliances AANA members – data collectors SOS – the data collection tool Hawkins Foundation – vehicle to identify

the correct data to collect and the reporting entity for

AANA/SOS/HF – Present & Future Within the greater SOS users group (SUG),

identify a dedicated group of SOS users/data collectors to address a specific NCD

Use the HF QCDR data sets to collect, analyze and publish “irrefutable” evidence

Research Ideal would be to compare surgical vs.

non-surgical – significant limitations Use the seven new HF risk adjusted

performance measures to determine how patients/surgeons do. If the patients can do well, we will extrapolate that data to protect patient access to care.

Thank You

MIPS January 1, 2017, CMS – Merit-based Incentive

Payment System (MIPS). MIPS Quality - Previously Physician Quality

Reporting System (PQRS) Advancing Care Information (ACI) - Previously the

EHR Incentive Program (Meaningful Use) Improvement Activities - Previously quality

improvement activities performed without reporting Cost - Previously Value-Based Payment

Modifier (starts in 2018)

Why Start Now? The 2019 payment adjustment schedule will be based on the

2017 performance metrics. In other words, provider performance in 2017 will be measured by the new MIPS scoring model and will have a direct impact on your 2019 reimbursements or penalties.

In addition to the payment adjustment, each eligible clinician’s MIPS CPS and individual performance category scores will be made publicly available on the Physician Compare website, including a comparison of the ranges of scores for eligible clinicians across the country. The sooner you can solidify a strong reporting strategy, the better prepared you’ll be for MIPS reporting success.

Why Start Now? The 2019 payment adjustment schedule will be

based on the 2017 performance metrics. Provider performance in 2017 will be measured by

the new MIPS scoring model and will have a direct impact on your 2019 reimbursements or penalties.

Eligible clinician’s MIPS CPS and individual performance category scores will be available on the Physician Compare website, including a comparison of the ranges of scores for eligible clinicians across the country.

What is the Bonus and Penalty Adjustment Schedule?

The MIPS score’s maximum impact on reimbursement increases from plus or minus 4% for the 2019 payment year to plus or minus 9% for the 2022 and subsequent payment years.

2017 Program Year MIPS will be the pathway for a majority of Orthopaedic Surgeons to participate in QPP. MIPS combines CMS's three existing reporting programs -

Physician Quality Reporting System (PQRS), Value-based Modifier, and EHR Meaningful Use, under a single entity. 2017 MIPS Metrics To calculate your MIPS score, CMS will evaluate your performance in four categories. Scores in each area will be weighted. CMS will adjust the weights

for each category each program year. Quality (Replaces PQRS) - 60% Must report 6 measures, 1 must be an outcome measure or high-priority measure You must report measures for 50% of your population regardless of payer Reporting may be completed via registry or through an EHR You will receive 3-10 points for each measure based on how your performance compares to the benchmark You can select any 6 measures or pick from the orthopaedic specialty measure set - In development Advancing Care Information (ACI) (replaces MU) - 25% Assigns credits for your use of a certified EHR. You will receive an overall score comprised of several elements:

Base Score Performance Score 5 Bonus Points for participating in a registry 10 Bonus Points for completing improvement activities related to Advancing Care Information Required reporting may be completed via registry, your EHR or the CMS portal

Clinical Improvement Activities (CPIA) - 15% New category in 2017 that focuses on care coordination, beneficiary engagement, and patient safety There are over 90 practice improvement activities to choose from, with medium or high weightings. 15 or Few Eligible Providers: Participate in one high-weighted or two medium-weighted activities to receive the full score of 20 points. 16 or more Eligible Providers: Participate in two high-weighted or four medium-weighted activities to receive the full score of 40 points. Report on these activities through a data registry or EHR List of orthopaedic-related improvement activities - In development Cost (replaces VBM) - 0% for 2017 No reporting will be required for this category. CMS will calculate your score based on claims data in 2017 and report it to you via feedback report Will not account for overall score in 2017 Scoring: A single MIPS composite performance score will factor in performance in the four weighted categories. Orthopaedic Surgeons can receive

positive or negative payment adjustments based on their composite performance score. There will be "winners" and "losers".

AANA Member Benefits Individual member

Use for MIPS satisfaction○ Report to CMS

Demonstrate quality commitment to local insurers Demonstrate outcomes data to surgical candidates